Ep 110: Insects and Animals bites--how to prevent and treat! Part 2: with David Epstein MD FAAP

This weeks episode of Ask Dr Jessica is part 2 with Dr David Epstein, a practicing board-certified pediatrician and pediatric critical care physician. In this episode we will discuss bites--how to avoid them and how to treat them!  We talk about bee stings, insect bites, cat bites, dog bites and even human bites! 

Please follow Dr Epstein on instagram @davidepsteinmd.  He also has a podcast called "Dr Dave's Pediatric Pearl's Podcast".  Also, check out his website!

Dr Jessica Hochman is a board certified pediatrician, mom to three children, and she is very passionate about the health and well being of children. Most of her educational videos are targeted towards general pediatric topics and presented in an easy to understand manner.

Do you have a future topic you'd like Dr Jessica Hochman to discuss? Email Dr Jessica Hochman askdrjessicamd@gmail.com.

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The information presented in Ask Dr Jessica is for general educational purposes only. She does not diagnose medical conditions or formulate treatment plans for specific individuals. If you have a concern about your child's health, be sure to call your child's health care provider.

Transcript

Unknown: 0:00

Hi everybody I'm Dr. Jessica Hochman, paediatrician, and mom of three. On this podcast I like to talk about various paediatric health topics, sharing my knowledge not only as a doctor but also as a parent. Ultimately, my hope is that when it comes to your children's health, you feel more confident, worry less, and enjoy your parenting experience as much as possible. Welcome to part two of my interview with Dr. David Epstein. Dr. David Epstein is a practising board certified paediatrician, a paediatric critical care physician and a podcast host. On today's episode, we are going to talk all about bites from insect bites beestings to animal and human bites, we're going to talk about it all. Dr. Epstein explains how to avoid bites, how to think about treating bites and when to see a doctor. Thank you so much for listening to today's episode. And if you'd like to learn more from Dr. Epstein, definitely check out his website, David Epstein md.com. Now Dr. Epstein, I'd love to talk to you about different insect bites and animal bites and human bites, I want to give families an overview on how to think about the various scenarios that come up commonly with kids. So first, I want to ask you about beestings we're just coming off of summer and I've seen a number of kids get beestings How should parents think about a bee sting? What's the first thing that they should do? Well, I think it's, you know, cleaning the wound, getting the stinger out, I think is is a reasonable thing to do. And then just cleaning like any other wound, oftentimes with insect and bee stings, there's a local inflammatory reaction from either the venom or just, you know, mosquitoes, they tend to, you know, whatever's going on with them, they tend to the body tends to react in some kids, but I kind of put them all into kind of, like, you know, like a kind of a one grouping is that there's a local inflammatory reaction, meaning that there's, there's swelling, there's redness, there could be some tenderness. So basically, that's the body's generic response to any invading bacteria or Venom or, you know, agent that's, that's foreign, it's what's that's what's going to happen. So, if your child doesn't have like a serious allergy to like bee stings or any other insects, usually what happens to varying degrees, they'll get a local inflammatory reaction, which is, you know, the the redness and swelling could be some a little bit tender, could be a little bit warm. And I usually tell families in that initial period, you know, first 24 hours, I say, most likely, it's not an infection. It's a local inflammatory reaction from the event itself, the venom or the or the sting, and to treat it with anti inflammatory agents. Usually, my first line is hydrocortisone 1% cream, getting it over the counter, do that twice a day, a cool pack, Motrin and an anti histamine. Now, again, as as dogma would have it, you know, everybody use Benadryl for a long time. And so we're trying to shift away from Benadryl now to something like more like like Zyrtec, which is an anti histamine in the last 24 hours, that doesn't cause drowsiness. And there are other other ones over the counter to like Claritin and things like that, that you know, it's something in anti histamine to reduce some of that reaction, the body's reaction. So those are the four things which I kind of go off first. And over the first 24 hours, I say do that, you know, diligently watch it closely. And if after about, you know, 2448 hours, despite that, if it starts getting worse, and the swelling gets worse, the redness gets worse, the pain or you see pus draining or it's really warm, then sometimes you can get a secondary bacterial infection, meaning the bacteria are invading the wound and causing a skin infection, at which point, then we'll do oral antibiotics. If the reaction is pretty significant initially, early on, and you come into the urgent care or or the or the office, and like the hand is swollen and tight from a beasting then sometimes we'll give steroids like you know, oral steroids to try to reduce that that inflammatory reaction but that's that's kind of how I compartmentalise it when I think of stings and bites. Your parents want to know if it's a spider bite or if it's an insect bite or if it's a mosquito by usually with mosquitoes I can kind of tell because, you know, they call them ankle biters. Basically, the lower legs, anything that's exposed, like lower legs, arms, face, that's where they're going to get, you know, the bites. And usually they're like multiple, you know, I can't differentiate between, you know, like a benign spider by eight or other insect and mosquito sometimes it's just it's too. It's too generic. Yeah, if it's a brown recluse or Black Widow, that's a little different story. But for the most part, it doesn't matter what the bite is it as much as how you treated that first, you know, 24 or 48 hours. So to your point, whenever you see a bite, you're going to treat it the same way. So what kind of bite exactly it is, if it's a yellow jacket or a wasp or mosquito as long as this thing is removed, you're going to treat it with hydrocortisone twice a day, an anti inflammatory like ibuprofen, a cool compress. And then an anti histamine no question about the anti histamine doesn't matter if it's topical, like a cream on the skin, or does it have to be taken by mouth? I usually do oral because that's it gives it's a little bit better penetration and usually the topical ones I don't see as much improvement with it. I you know, it's like, it's like when the I don't know, there was a fad. I don't know if you know giving oral albuterol you know, for asthma, you know, there's we just don't do it. It's it's not going to the place where we need it to go. You know, so, you know, we don't do oral albuterol or albuterol syrup. We do inhaled albuterol. So it's kind of similar mechanism. I think, you know, you want it to get into your system and fight the inflammatory response in the topicals just not going to do it for Yes, I find that a topical Benadryl really just doesn't do much at all. Yeah, yeah, of course the side effects Unfortunately, your kids can be tired. Maybe that's maybe that's a plus for some parents. Exactly. Exactly. But you got to be careful. I actually it's funny. My, my mom tells a story when when I was little, and they were taking she was taking me on a plane for the first time. And she wanted me to rest and be calm. She gave me some Benadryl. But instead of having that reaction to sleepiness, I had the paradoxical reaction, which made me flip out of my mind and was agitated running up and down the aisle. And now Yeah, so you part of that? 5%? I guess? Reaction? Yeah, I guess I know, that's a good, that's a good point for parents to hear it and don't try Benadryl for the first time on an aeroplane. Yes, it is contained. Yes. Okay, so and then I want to talk about the question of antibiotics or not. So what I've learned is that the bee sting in general is so small creates such a small notice or hole in the skin that it really rarely causes a true secondary infection. And that there's a good subset of kids like five 10%, that have these big reactions 24 or 48 hours later with a skin really swells. And it's not actually an allergy, it's what we call a large localised reaction. So when you see kids that have larger, like larger sites of swelling, do you still treat them with antibiotics? How do you distinguish between who needs an antibiotic and who doesn't? Yeah, that's a good question. And it's really, it's really difficult in certain situations, because, you know, it's like you, if it's, if it's an early on, it's like a no brainer, I'm like, it's, it's not an infection, it's, it's a reaction. But as time goes on, you become less confident. In that, you know, you know, 48 hours, 72 hours, you know, you're like, Okay, it's read still, it's a, sometimes the longer it goes on, the more concerned I get, that the, the telltale signs that it is a real infection, is I look for streaking, which, you know, I'll usually see like, if it's on the hand, you'll see streaking up the arm, and like a little red streak, and then if you feel under the into the armpit, you'll feel like a lymph node, and it will be a little bit tender. And so in those instances, it doesn't matter what the timing is, if if I see that they're going on antibiotics, you know, same thing with with the leg if there's you know, foot and you see streaking up the leg, it's basically the the lymphatics are, are draining whatever is going on in that area. And oftentimes, you know, the infection causes the bacteria causes that inflammation in that redness, so it's streaking, I haven't seen them or anything else, it's kind of have that same kind of reaction, it's more localised, so when it's it starts spreading up the lymphatics and you get that streaking, that's usually more of an indication that it's a bacterial infection. And just so parents can picture this, you're saying typically the large local reactions a circle, like it's a nice discreet circle, and if it starts making lines or streaks that come from that circle that makes you suspicious of a secondary infection that would require antibiotics. Yeah, yeah. It's like it's more like yeah, you'll see like a patch or you'll see some swelling like the hand swollen everything, and it could be, you know, big, red and swollen and to your Your point yes, you know, the the, the envenomation from a bee can last, you know, for a couple of days and sometimes it can be a little longer. So, it's always good to just check in with your paediatrician to evaluate, reevaluate, because it's like one of those things just to reevaluate. And that and just a side note with anything that we see in the urgent care or an office, the best care that you're going to get is from follow up. So if you have any questions, or you need any advice, the follow up is key. You know, seeing a child who's in respiratory distress coming in for you know, wheezing, from asthma breathing, you treat them, they look better. Follow up with your paediatrician tomorrow, because you need to reassess to make sure things are going in the right direction. Same to with wounds, skin infections, stings that are pretty large that aren't, you know, that you're concerned about? The follow up is key. No, I thank you for that point. Because I agree that there's a lot of education that we provide at the follow up visits, we tell parents what if it happens, again, what to look for, you know, when it's a calmer moment when things aren't so urgent, I think it's there's a lot of value in those follow up visits. Oh, definitely. Definitely. And and, you know, I think it gives it will give the parent peace of mind too, because it'd be like, if things were better, and then all of a sudden, they get worse, they'd be like, Okay, well, what, you know, maybe I should have follow it up. And, you know, you kind of get in that conundrum where you're like, you're not sure what to do. And so the best thing you can do is just just to make a phone call even a phone call to your paediatricians office or just visiting. You know, it's helpful. It's helpful. Yeah. Now, I'm curious, from your standpoint, have you seen a lot of visits for mosquito bites this season? Because I know I get a lot of visits from really scratched or excoriated mosquito bites. Is that something that you see in what what do you advise to parents to tell their kids about mosquito bites? Should they not touch them? Should they treat them the same way? Yeah. Yeah, summers are always rough. I mean, this year hasn't seemed as bad I think, a couple years ago, like, I don't remember, it was like, there was bananas, it was like, it was like everybody, but I've seen a good good share of mosquito bites. And I think the times that you gotta be careful are, you know, dusk, that's kind of when they start to come out. So playing, if you're playing outside, I know, it's hard to get summer and it's warm, you know, obviously, long pants and long shirt, but it otherwise you know, you can put some repellent and mosquito repellent on or things like that. But just know that dusk is kind of when they start to come out. Also miski Icy mosquitoes were, you know, they're in the house, and they get in the house from the outside. And so they have free rein all day all night. And they're snacking. So that's, you know, that happens. Obviously, like you said that, you know, the mosquito bites are itchy, and kids want to scratch them, and it's hard not to want to scratch them, it's hard telling a toddler don't scratch, you know, because they're gonna they're, they're just going to do it. So the best thing you can do is just hop on treatment right away, as soon as you see a little dot there. And it looks like there's a little inflammation and you see them kind of reaching for it scratching, start putting the the 1% hydrocortisone cream on doing the things you know, cool, pack it anti-histamine You know, a little ibuprofen just to kind of stop that because as soon as it starts to get to that point where it's really itchy, they're gonna keep scratching and they're gonna be like, it's gonna, then it's gonna get infected, then then you know, the wound opens up and you know, because of the scratch marks and then then they can get a secondary infection for that. I also find with mosquito bites, once they're bit it's really hard to control the edge, even with all the measures that we can offer. Yeah, so a lot of parents they try. They're, they're nervous to use traditional insect repellents like DEET and I find that the natural stuff doesn't really work. Yeah. And so I would rather just make sure my kids don't get bit make sure I don't get bit so I don't know how you feel, but I definitely recommend dt to my patients. Yeah, yeah, no, I think that's I think that's reasonable. I, the, the other thing that actually can can help with itching, and maybe reduce infection a little bit is sometimes I'll recommend like Epsom salt baths, you know, like a like a little quarter cup of epsom salt and a warm bath up to their waist, just let them sit in it. You know, if it's on their lower extremities, which it usually is on their lower legs, you know, let them soak in there for like 10 minutes or something like that. And then and then dry them off and maybe put a little hydrocortisone on after you know after the bath and that may help but again, you're right. Once they get bit, it's hard to control the itching. Now, what about bites? So I just want to talk about animal bites because a lot of kids come in with dog bites. So I'd like to start off For dog bites, how should parents think about dog bites in general? Do they always need to see a doctor? Are they always going to need to be on an antibiotic? What's the deal with dog bites? That's a good, that's a good question. You know, minor bites, like if it just kind of breaks the skin a little bit, you know, we're like, you know, we cleaned it out really well, maybe, in those kids sit in those situations, I'll put antibiotic ointment on because any bites are really considered dirty. If it's a significant to where it's an open wound, like it's gaping, or it's, you know, it's seems like it's pretty deep. I think I will put them on antibiotics. If it's a laceration that we're repairing from a dog bite, I will put them on antibiotics. It's interesting. The wounds you know, and actually, there's a plastic surgeon in the area. Dr. Andrew Cohen. He's really, actually a shout out to your podcast and your episode with him. It was a great episode. Everybody should listen and learn more from from your podcast, Dr. Epstein's pearls. Tell me that remind me the title. Let's hear from Dr. Dr. Dave's paediatric pearls. I will link the great episode where he talked more about this in the show notes below with you and Dr. Cohen. Perfect. Vaccines pearls. Yeah, he's he's a great, he's a great resource. And he's, we've worked together many times on dog bites and the thing with dog bites. You know, I don't I mean, I worry about the infectious part. But most of the time the dog bites seem to be on kids faces because they're bringing their faces you know close to the dog and they get scared they nip and thing it's not that the dog tried to do something you know, bad you know to try to chew on your your child or somebody else's child it just that you know, they were the wrong place the wrong time. And you know, that just happened but so dog bites on the face, I will usually relegate to a plastic surgeon just for cosmetic purposes. And he's really good at doing that. Even though it's a dog bite, you still close the wound because you want you want it to heal. And then you treat with antibiotics. Subsequently with that, but wounds on the face usually heal pretty well. It's a well vascularized area and so they the healing is good. Sometimes, depending on the extent of the bite, I mean, there there can be scarring. And that's why putting putting the care in a plastic surgeon in those situations is I think, pretty reasonable. Now, what about cat bites? You talked about how a dog bites you close the wound with sutures. If it's lacerated, what about cat bites? Different? Are they treated differently? Yeah, I think cat bites usually. You know, we don't see them as commonly as dog bites. Usually cat bites are more like puncture wounds. And, you know, they still have the risk because it's a it's a punctured, it's usually like a deep puncture. And you can't really, I will put them on antibiotics, you know, for those human bites. You know, there's, those are the worst. You know, where it comes up the most is with toddlers. Yeah, yeah, exactly. But yeah, so those are definitely, you know, treated with antibiotics. So, you know, it's a spectrum. But I mean, the main thing, if there is a bite, you want to you want to clean the wound out very well. And you want to seek medical advice, because it's sometimes hard to differentiate. Because, yeah, you may have gotten a bite, but it may be superficial enough where it maybe doesn't need anything, or it may be a puncture wound that is deep that you want to make sure it doesn't get infected. So, you know, I always recommend if there is a bite, you're concerned and breaks the skin, you know, have your child seen because chances are if it's a if it's a cat bite, and it's, you know, a deep puncture, we'll probably do antibiotics. If there's a dog bite, and it breaks the skin and there's a wound and it's significant. Definitely do antibiotics even if you're not going to suture it. So just to summarise, it sounds like with any bite if it's a if it's a minor scrape doesn't seem to break the skin surface, clean it and observe it. And if there's any question and breaks the skin or there's question about the depth or the cosmetic appearance, definitely see your doctor. Absolutely. And expect to be put on an antibiotic there's a good chance you'll be put on an antibiotic like augmentin. Yeah, exactly. Exactly. Now, what about preventing dog bites? I just want to mention this because I do think there are things that parents should be aware of to prevent dog bites for their kids. Yeah, I think it's hard because every family has their own culture with regards to their dog. And there are different breeds of dogs that are more aggressive than others. I'm not I'm not a specialist in in dogs. Uh, but I Yeah, but I do know, you know that, that that dogs can be scared like, you know, if somebody comes up behind them like a toddler and touches them, sometimes they can turn around and you know, they're they may be unpredictable to certain extent, maybe larger dogs obviously they have a stronger job they're you know bigger teeth, they can take a bigger chunk, but smaller dogs can also cause cause injuries a actually, the story of Dr. Cohen he did bring somebody in, who had like a like a beagle and the Beagle, you know, nipped the lip, and then actually cut through the lip. And so we have to suture the lips. So it may not be necessarily a big bite, but it could be a bite in a bad place, like, you know, on the lip, or you know, something on the face, which could cause some cosmetic issues. One thing I tell parents, is to remind their kids not to bother a dog while they're eating. Because I find if I have a hungry dog may may reach back and nip or bite. Yeah. And a lot of kids will see a dog on the streets, and they'll pet the dog. And I think it's a really important reminder for parents to tell their kids to ask first before they touch a dog to make sure the dog is friendly. So sometimes you'll ask parents that are holding dogs, and they'll say no, don't touch my dog. This is our friendly dog. Yeah, yeah, absolutely. I think that's, that's really good advice. I mean, but I always caution parents that even if it's their own dog, because like, a lot of times we'll see where it's they're actually the patient's own dog that did the biting. And it was more like, like you said, they surprised them they were eating or they tried to pull a toy away from them, or the dog got scared, or they're just getting their face too close. You know, they're giving kisses and whatnot and getting their face too close. And, you know, we have dogs and I'm like, I'm always telling my kids, I don't put your face close to the mountain, you don't know what's going to happen. I have to tell you, I have a new puppy, who's three months old. And I get very nervous because my kids do get very close to her face. And she's very nippy. And I say as soon as I hear her growl, I really tell them to step back and just leave her alone. Because I I've seen one too many dog bites. Yeah, yeah. And it doesn't have to be a big bite. It just like, like I said before, it just has to be a bite in the right place, which can cause a lot of trauma, you know, like, like a lip. You know, you just get a little nip on it, and then it cuts through the lip, and then you're, you're going for sutures and the sutures, it's not easy to suture, or close a lip wound, you know? So prevention is key. Yeah, for sure. And then just to there's a myth going around that I just I'm curious if you know the answer. Is it true that a dog's mouth is cleaner than a human mouth? Because I've heard people say that dog bites are actually cleaner than a human bite would be. Is there any truth to that? Yeah, I you know, I don't know. I don't know the answer. But I know human bites are pretty dirty. So. So myth was, my husband said that to me this week. And I said, I'm not really sure if this is true. I'm gonna ask Dr. Epstein. Yeah, I just I just think anybody I mean, you know, our, our mouths, you know, our whole GI tract were filled with bacteria. I mean, that's, you know, that's, that's what it is. So any any bite is a risk for infection. Yes, I said this too, especially after watching our dog, like, lick parts of their body. They shouldn't be licking so yeah, makes Yeah, he's gonna be that clean? No. Okay. Definitely. You know, they're, they're smelling the poop. And, you know, for trying to figure out who that is. You're like, Yeah, you really want to touch that. And here. This has been so helpful. Thank you so much. If parents want to see you, is there a place that they can learn more from you or see you? Sure? Sure. I have a website that has a lot of collated information. It's basically David Epstein. md.com. And then any of my handles on social media or David Epstein, MD So on Instagram, and ex threads. LinkedIn, Facebook, you know, that's all that stuff. So amazing. And I hope you get back to your podcast soon. The episodes you put out were really, really wonderful. Oh, thank you. Thank you. Yeah, I will. I will. I just need a little bit of respite. And I'll get to it. So but you have a great, great podcast yourself. And I wish you all the best with everything. And it sounds like you're doing a great job. Thank you, Dr. Epstein. Thank you so much. Oh, my pleasure. Thank you for listening. And I hope you enjoyed this week's episode of Ask Dr. Jessica. Also, if you could take a moment and leave a five star review wherever it is you listen to podcasts, I would greatly appreciate it. It really makes a difference to help this podcast grow. You can also follow me on Instagram at ask Dr. Jesse